Minnesota Department of Health
Statewide Health Improvement Program
Clinical-Community Linkages for
Prevention
Guide for Implementation
FY2014-15
Clinical-Community Linkages for Prevention – last updated 6/2013
Contents
Background for Strategy ..................................................................................................... 3
Clinical-Community Linkages .......................................................................................... 3
Advancing Public Health, Health Care and Community Linkages with State and Federal
Health Reform Initiatives ................................................................................................ 5
Clinical-Community Linkages Component .......................................................................... 6
Priority Populations ........................................................................................................ 8
Scope of Component ...................................................................................................... 8
Phased Approach ............................................................................................................ 8
Planning and Assessment ............................................................................................... 9
Process 1: Community Linkages.................................................................................. 9
Process 2: Clinical Linkages ....................................................................................... 14
Continuous Quality Improvement for Prevention ........................................................ 19
Step 1: Screen ........................................................................................................... 19
Step 2: Counsel ......................................................................................................... 23
Step 3: Refer.............................................................................................................. 26
Step 4: Follow-Up ...................................................................................................... 32
Sustaining Long-Term Change ...................................................................................... 35
Innovations or Promising Practices .............................................................................. 35
Advancing Public Health, Health Care and Community Linkages with State and Federal
Health Reform Initiatives Strategy .................................................................................... 36
Scope of Component .................................................................................................... 36
Requirements .................................................................................................................... 37
Recommended Partners and Potential Responsibilities................................................... 38
Training and Technical Assistance .................................................................................... 40
Appendices........................................................................................................................ 41
References ........................................................................................................................ 42
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Background for Strategy
The Clinical-Community Linkages for Prevention strategy has two components: ClinicalCommunity Linkages and Advancing Public Health, Health Care and Community Linkages
with State and Federal Health Reform Initiatives. Grantees are required to progressively
work on both components.
Clinical-Community Linkages
The numbers tell the story. In 2009 approximately 63 percent of Minnesotans were
overweight or obese, and 17 percent of Minnesotans used tobacco products. The annual
obesity-related medical cost is estimated to be $1.5 billion dollars, of which $626 million
are Medicaid and Medicare expenditures. Annually, smoking costs Minnesota nearly $3
billion in health care cost. Overweight and obesity also increase the risk of many chronic
diseases such as diabetes, heart disease, some cancers and arthritis. This epidemic is
placing a huge burden on our health care system and economy. It also underscores the
important role of the health care system as a setting for addressing nutrition, physical
activity, and tobacco use behaviors.
The U.S Preventive Services Task Force (USPSTF) has made recommendations that
include a broad range of clinical preventive health care services such as screenings,
counseling, referrals, and preventive medications. Despite the existence of the USPSTF
recommendations, patients receive only half of the recommended clinical preventive
services overall, and less that 20 percent of recommended counseling or education
services.1 A promising approach to enhancing the delivery of preventive services in
clinical settings is for providers to coordinate, cooperate, and collaborate with external
nonclinical organizations such as local health departments and community-based
organizations that share an interest in improving health and preventing disease and can
provide these services.
Primary care practices that attempt to implement guidelines like these face challenges
related to available resources, appropriate training, and time necessary to build new
capacities for behavioral counseling and follow-up care. Research has shown that
practices have the potential to overcome these challenges by combining clinical efforts
with community partnerships. When they do, studies show that patients’ health
behaviors improve.2 Infrastructure support and communication systems must be
developed to foster sustainable linkages between practices and local resources. This
SHIP strategy allows grantees to develop the support and systems needed for ClinicalCommunity Linkages for Prevention.
Clinical-Community Linkage Framework
The Etz Bridging Model3 (Figure 1) depicts a “clinic-community linkage.” The bridge has
2 anchors and a bridge span. The anchors illustrate a set of characteristics on the
clinic/clinician side that influence the ability to initiate connections to community
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resources, and a set of characteristics on the community resource side that facilitate
connections to primary care practices. These attributes can be considered foundational
anchors that must be established at each side of the bridge for a clinical-community
linkage to be developed. Anchoring characteristics on the clinic/clinician side include the
capacity to assess patient risk, ability to provide brief counseling, capacity and ability to
refer, and awareness of community resources. Anchoring characteristics on the
community resource side include the availability, accessibility, affordability, and
perceived value of services provided by the community resource. Strategies created to
connect clinical practices and resources can be considered as the bridge span to connect
the gap between primary care and community resources.
Figure 1. Bridging Primary Care and Community Resources: Model Elements
Connecting Strategies
Opportunity
to activate
Pre-identifying community resources

Known services and expectations
Developing referral guides

Electronic databases
Engaging external intermediaries

Single-point access to resources
Opportunity
to encourage
Patient Referral
Communication between anchors
Capacity for screening (risk assessment)
Ability for brief counseling
Awareness of community resources
Capacity and ability to refer and follow up
Anchor – Primary Care
1.
2.
3.
4.
Availability of resource
Affordability of resource
Accessibility of resource
Perceived as value added
Anchor – Community
Resources
Steps taken to initiate the bridging process;
Primary care practice characteristics (anchor);
Resource characteristics (anchor); and
Steps taken to make effective use of the bridges, once established.
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Advancing Public Health, Health Care and Community Linkages with
State and Federal Health Reform Initiatives
Minnesota has been a leader in pursuing policies to improve the health care system.
Health Care Homes, also known nationally as Patient-Centered Medical Homes (PCMH),
are an important cornerstone of the 2008 MN Health Reform law. The health care home
is a transformative change in the delivery of primary care. The health care home
concept focuses on a broad continuum of health and incorporates expectations for
engagement of the patient, family and community. The aims are to improve the health
and quality of life for patients, to connect the health care delivery system with the
community and improve population health.
The United States is a recognized leader in many areas, but our healthcare system has
been labeled as “broken” by many policymakers and thought leaders. However, with the
passage and implementation of the Affordable Care Act (ACA), the U.S. is engaged in
significant efforts to transform the healthcare system. A fundamental premise of
healthcare transformation is that silos need to be reduced or eliminated and a more
integrated and coordinated system must be developed.
In an effort for health care to shift the focus from individual patient care to population
health management, the ACA promotes the establishment of accountable care
organizations (ACOs). An ACO is a group of coordinated health care providers that work
together to care for a designated population4 As health systems in Minnesota are
developing reforms such as Health Care Delivery Systems, ACOs or Accountable
Communities for Health, they should be encouraged to incorporate community-based
prevention such as SHIP interventions into their systems.5 An investment in prevention
and coordination with SHIP as part of these overall models can help providers more
easily and effectively reach their goals of healthier communities and lower health care
costs.
In addition, the ACA regulations require each tax-exempt hospital to do a “Community
Health Needs Assessment” every three years. This assessment must include input from
the community served by the hospital and from those with expertise in public health.
Hospitals must adopt an implementation strategy that addresses the community health
needs identified by the assessment.6 This may free up the hospital’s community benefit
dollars, formerly dedicated to charity care, to be used for community prevention
initiatives including programs identified in SHIP i.e. National Diabetes Prevention
Programs and Diabetes Self-Management Programs, Chronic Disease Self-Management
Programs, etc.
Framework
The Expanded Chronic Care Model (Figure 2) represents a framework that can re-orient
public health and healthcare services to better address the needs of individuals with
chronic disease(s). The framework places greater emphasis on prevention, population
health promotion, and the creation of supportive environments that are linked to the
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health care system.7 This enhanced version of the Chronic Care Model includes
elements of the population health promotion field so that broadly based prevention
efforts, recognition of the social determinants of health, and enhanced community
participation can also be part of the work of health care/system teams.
Figure 2. The Expanded Chronic Care Model: Integrating Population Health Promotion
Barr, V. J., Robinson, S., Marin-Link, B., et al. (2003). The Expanded Chronic Care Model: Integrating
Population Health Promotion. Retrieved May 22, 2013. From http://www.longwoods.com/content/16763
Clinical-Community Linkages Component
The SHIP approach to Clinical-Community Linkages is founded on true collaboration
between health care clinics, local public health (LPH) agencies and community-based
organizations (CBOs), and healthcare systems. The objectives for this strategy are:
1. Convene and strengthen partnerships between LPH, health care facilities and
clinics, health plans/payers, and community-based organizations that are
committed to addressing obesity and tobacco use/exposure.
2. Enhance methods for screening and documentation of Body Mass Index (BMI)
and tobacco use and exposure status.
3. Provide technical assistance to clinicians and clinic staff on effective practices
and approaches for addressing BMI status and tobacco use and exposure with
patients, including motivational interviewing and goal setting.
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4. Identify, catalogue and make available to clinicians, clinic staff and patients
community resources that address behaviors related to nutrition, physical
activity, and tobacco use and exposure. This may include uploading resources to
a statewide online database and integrating resources into electronic medical
record (EMR).
5. Create or strengthen system of referral to in-house or community resources.
6. Develop or enhance a follow-up system.
7. Promote usage of existing billing codes for reimbursement of services provided
related to the SHIP strategy, Clinical-Community Linkages for Prevention (i.e.,
counseling, nutrition education, follow-up care).
The Clinical-Community Linkage component includes the following steps:




Assess and plan to increase access to evidence-based lifestyle change and
prevention programs.
Facilitate infrastructure development to increase access to evidence-based
lifestyle change and prevention programs in the health care facilities and in the
community.
Partner with local clinics to support the implementation of evidenced-based
clinical guidelines and the clinical system process of Screen, Counsel, Refer, and
Follow-up**.
Support the use of health care extenders (i.e. health educators, community
paramedics, nutritionists, etc.) to improve engagement of disparate populations
in evidence-based lifestyle change and prevention programs.
**Origin
The SHIP clinical system process of Screen, Counsel, Refer, and Follow-up was adapted
from evidence-based guidelines and recommendations, including:
 The Institute for Clinical Systems Improvement (ICSI) Prevention and
Management of Obesity (Mature Adolescents and Adults) and Healthy Lifestyles
(formerly Primary Prevention of Chronic Disease Risk Factors).
 The American Academy of Family Physicians (AAFP) Ask and Act Tobacco
Cessation Program, “The Five A’s Of Tobacco Cessation Support.” The 5A’s (Ask,
Advise, Assess, Assist, and Arrange) are reflected in the Clinical-Community
Linkages for Prevention strategy (see Appendix A for a diagram depicting their
overlapping relationship).
Please also see Appendix B: References for supporting literature, Appendix C: Talking
Points for Prevention in Health Care, and Appendix D: Terminology and Abbreviations.
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Priority Populations
The populations for the Clinical-Community Linkage strategy include patients, regardless
of age, who are identified as being overweight or obese and or using/being exposed to
tobacco. Priority patients within these population include patients who are uninsured
or on Minnesota Health Care Programs such as Medicaid, Medicare, or MNCare,
pregnant women to include breastfeeding education and, adults with mental illness and
adults over the age of 60.
Scope of Component
The approach to the Clinical-Community Linkage component is founded on true
collaboration between health care clinics, local public health (LPH) agencies and
community-based organizations (CBOs). In relation to the Bridging Model, the
collaboration is the bridge span strengthened by the grantee; the strategy steps of
Screen, Counsel, Refer, and Follow-up ensure that Primary Care anchor has a strong
foundation; and the step of Creating/Identifying Resources (availability, affordability,
accessibility) ensures that the Community Resources anchor has a strong foundation.
Phased Approach
During the application process, applicants will place themselves in one of the following
three phases. The evaluation expectations, grant monitoring milestones and level of
training and technical assistance will vary for each phase. Please read through this Guide
for details to help you determine which phase is the most appropriate to begin
activities.
Phase 1 | Partnerships and Planning
Applicants have limited partnerships within the strategy work. They are just beginning
to address health inequities within their community. The focus is on planning, assessing
and engagement and they will likely begin with a more step-by step approach. The
choice of phase doesn’t necessarily reflect experience. Applicants may choose this
phase if they are starting work in a new community or a new setting within a content
area that is already familiar to the grantee. The level of technical assistance and support
for this phase is significant and will be provided in a timely fashion. This phase is
intended to be short-term; exact details will be negotiated in final work plans.
Phase 2 | Growth
Applicants have strong partnerships and consistent experience within this content area
and setting. They will build on existing partnerships and expand to additional sites,
addressing health inequities and supporting policy development and regional efforts.
Training and technical assistance needs should be able to be met through regular
contact with an assigned Community Specialist, consultation with MDH content experts
and regularly-scheduled trainings.
Phase 3 | Innovation and Promising Practices
This allows for innovation by grantees and their partners, addressing cutting edge policy,
systems and environmental change. The strategies selected will or have decreased
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health inequities. Potential is high for new models and learning. Minimal formal
technical assistance is planned for this phase but will be delivered as needed.
Phase 1: Partnerships and Planning
Those that select Phase 1 will develop relationships among health care providers and
community leaders; build partnerships; and identify gaps and resources that facilitate
active referral of patients to local resources which increase access to high quality
nutritious foods, opportunities for physical activity, tobacco use cessation and evidencebased self-management programs.
Phase 2: Growth
Those in Phase 2 have demonstrated they have at least one partnership in place and
have conducted an environmental scan of the local resources. The grantee will support
infrastructure development to increase access to evidence-based self-management
programs in the community; support the SHIP model of Screen, Counsel, Refer and
Follow-up with additional health care partners; and support the implementation of
evidence-based clinical guidelines.
Phase 3: Innovation and Promising Practices
In Phase 3, grantees will identify additional health care partners in their community to
address health disparities.
Activities
Planning and Assessment
Planning and assessment are critical aspects of SHIP as they prepare both grantees and
community partners for implementation of evidence-based strategies. SHIP grantees
must complete the two processes described in this section (Process 1: Community
Linkages and Process 2: Clinical Linkages) prior to implementation of the ClinicalCommunity Linkages for Prevention strategy steps.
Process 1: Community Linkages
#1:
Organize an
Area
Health
Advisory
Council
#2:
Engage
Community
Stakeholder
#3:
Identify
Gaps and
Barriers to
Referrals
#4:
Compile an
Inventory
of Local
Lifestyle
Change
Programs
#5:
Create a
Community
Action Plan
1. Organize a SHIP health area advisory committee
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The purpose of an area advisory council is to allow health care and community
conversations on what works, address common issues or concerns related to
implementation, and strengthen the relationship between community referral
organizations and clinics through collective problem-solving. Members may include
(but are not limited to): representatives from the Community Leadership Team,
clinician champion from local clinics, clinic representative (clinic manager), LPH staff,
health educators, and patients and representatives from select community-based
organizations (that offer resources for nutrition, physical activity, and tobacco via
referrals), depending on the area capacity. A grantee would not have to organize a
new council or committee if a similar committee already exists and could complete
the following activities:
i.
ii.
iii.
iv.
Identify potential partner groups and send letter of invitation.
Add new SHIP partners as recruitment proceeds.
Propose dates for meetings.
Upon assessing availability, schedule regular meetings (every month or
every-other month).
Potential Milestones
 Planning group formed
 Materials developed for meetings: agendas, list of attendees, presentations,
and tools
Resources
 Minneapolis MGI Health Care Work Group (Appendix I)
2. Engage community stakeholders
A. Develop a list of key community stakeholders and community agencies to
conduct assessment—if applicable, consider getting contacts from an inventory
of existing programs.
B. Conduct Community Stakeholder Engagement through key informant interviews
to solicit community and culturally relevant feedback on 1) community resource
access, barriers, and needs; 2) needs and preferences for a referral/resource
system; and 3) developing relationships among health care providers and
community leaders to build partnerships for active referrals.
C. Compile document of key findings and recommendations.
D. Get feedback from area health advisory committee.
Potential Milestones
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


List of stakeholders assembled
Key informant interviews completed and information summarized
Key findings and recommendations from community/stakeholder engagement
activities are incorporated into work plan
Resources
 Referral and Resource Key Informant Interview Themes, Minneapolis SHIP 2010
(Appendix X)
3. Identify resource gaps and barriers to referrals
A. Work with partner clinics to assess clinics to identify current clinic-specific
referral resources through general assessment processes such as clinic
assessment, provider surveys, provider focus groups and patient surveys.
B. Identify gaps in community and clinic based programs at individual clinics
through assessment.
C. Obtain feedback from providers on current referral process and needs
1) To identify opportunities for process improvement within the clinics; and
2) To inform the development of a broad-based referral directory. Discuss when
to implement a quality improvement cycle for adapting clinic processes (i.e.
before or after formal referral system is developed). To be conducted after the
initial Clinic, Provider, and Patient Surveys are complete and before intervention
implementation.
Potential Milestones
 Clinic-specific resources identified and list developed
 Community-specific resources identified and list developed
Resources
 Health Care Provider/Staff Focus Groups: Informed Consent and Questions
(Appendix J).
 Americans in Motion–Healthy Interventions (AIM-HI). Offers resources for
family physician practice staff who want to serve as role models for patients.
See page 7, step 3 of the AIM-HI Practice Manual for information on
adjusting office processes and procedures.
http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/pub
_health/aim/practicemanual.Par.0001.File.dat/AIMPracticeManual.pdf
 Healthy Ohio Program - Creating Healthy Communities Checklist: Health Care
Setting Checklist, pages 9-18.
http://www.healthyohioprogram.org/~/media/HealthyOhio/ASSETS/Files/cr
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

eating%20healthy%20communities/creatinghealthycommunitieschecklist.ash
x
SHIP Clinic Assessment Summary Form (Appendix K)
SHIP Health Care Action Plan Tracking Worksheet (Appendix N)
4. Compile an inventory of existing resources and populate resource database (detail
below)
A. Research and compile existing clinical, community and self-management
resources through research, interviews, and assessments.
B. Develop an internal database or list to organize resources.
i.
ii.
iii.
iv.
Consider using MNHelp.Info inclusion criteria
Consider limiting your list by your jurisdiction or area served by clinics
Be sure to include programs in your area
Collect key data points identified in patient and staff/provider
assessments (e.g. cost, location, etc.)
C. Ensure the statewide resource database (MNHelp.Info) is populated with
compiled resources.
i.
ii.
iii.
Familiarize yourself with key features of resource database MNHelp.Info.
Complete MNHelp.Info excel template with compiled resource
information.
Submit MNHelp.Info excel resource spreadsheet to MNHelp.Info. Note
that MNHelp.Info will: determine taxonomy and terms; send each agency
an email indicating that their organization has been invited to be listed in
the database; and provide instructions on how to log-in and enter/update
agency and program information.
D. Conduct community agency outreach to notify them of MNHelp.Info and
encourage participation.
i.
ii.
iii.
Work with community organizations of interest to develop and enter
standard information into MNHelp.Info by populating MNHelp.Info
agency survey’s for each organization with information to be listed on the
database (e.g. cost, hours, languages, key descriptions of services, etc.)
Hold community events to notify community organizations and clinics of
MNHelp.Info and provide a tutorial on how to enter and update agency
information, how to search the system, and how to save searches etc.
Share compiled resources with other SHIP grantees, community agencies,
clinics and other clearinghouses such as United Way 2-1-1.
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Potential Milestones
 List of resources for referrals is developed and sent to MNHelp.Info (and
other clearinghouses such as United Way 211 and if applicable, county or
health system/clinic websites)
 Resource database is populated
Resources
 MNHelp.Info Inclusion Criteria (Appendix Y)
 Resource Database Attributes and Values (Appendix Z)
 MDH SHIP Guide 2008 List of Evidence-based Resources (Appendix AA)
 MNHelp.Info SHIP Information Sheet (Appendix BB)
 MNHelp.Info Excel spreadsheet template (Appendix CC)
 MNHelp.Info PowerPoints – MHI Power User Version (Appendix DD)
 MNHelp.info PowerPoints – MHI Provider Portal Instructions (Appendix EE)
 MNHelp.Info Saved Plans Guide, Minneapolis (Appendix FF)
 MNHelp.Info Keyword Search Guide, Minneapolis (Appendix GG)
 Resource and Referral Network Aggregate Baseline Assessment Findings,
Minneapolis (Appendix HH)
5. Create a community action plan to support resource infrastructure development
Using results from the assessments, grantees will work with area health advisory
council or committee to determine which evidenced-based lifestyle program(s) they
would like to establish in the community and who would sustain it. The following are
MDH-approved programs for adults:



Diabetes programs (i.e., National Diabetes Prevention Program, I CAN
Prevent Diabetes, Diabetes Self-Management Program) – modest 5-10
percent weight loss by increased physical fitness, improved diet, increased
self-monitoring and self-care
Chronic Disease Self-Management Program – demonstrated increase in
physical activity and healthy eating
Other evidence-based programs identified for specific populations, e.g.
pediatrics, patients with mental illness, older adults – approval from MDH is
required if SHIP funding is to be used to establish the program
A. Outline priorities and focus areas with planning group.
B. Create overall action plan with timelines for addressing priority(ies). The action
plan is to include recruitment of organizations to offer program (s), number of
staff to be trained, and logistics for training. SHIP will provide TA and guidance to
support planning and implementation.
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Resources for Adult Programs
 I Can Prevent Diabetes http://www.icanpreventdiabetes.org/index.html
 National Diabetes Education Program http://ndep.nih.gov/
 Minnesota Association of Area Agencies on Aging
http://mn4a.org/partners/evidence-based-programs/
http://www.mnhealthyaging.org/FindAClass.aspx
 Minnesota Arthritis Program
http://www.health.state.mn.us/divs/hpcd/arthritis/text/mnarthritis.htm
Resources for Pediatrics Program
 Minnesota Breastfeeding Coalition http://mnbreastfeedingcoalition.org/
 Baby-Friendly Hospital Initiative http://www.babyfriendlyusa.org/aboutus/about-baby-friendly
 American Academy of Pediatrics- Minnesota Chapter – Pediatric Obesity
http://www.mnaap.org/obesity.htm
 Action Plan templates
o Minneapolis SHIP Resource and Referral Network Clinic Action
Plan template (Appendix M)
o Clinic Action Plan Tracking Tool (Appendix N)
o Carver-Scott Health Care Action Plan template (Appendix O)
Process 2: Clinical Linkages
#1:
Recruit
Clinic
Partners
#2:
Establish
ClinicSpecific
Planning
Groups
#3:
Collect
Baseline
Assessment
Data from
Clinic
Partners
#4:
Analyze
Baseline
Assessment
Data
#5:
Develop
Clinicspecific
Action
Plans
1. Recruit clinic partners
Grantees will provide information to clinics and other health care sites about SHIP
and the Clinical-Community Linkages for Prevention strategy. Outreach should
include information on how prevention can fit in with the clinic or health care
system’s current or changing workflow processes.
A. Obtain a list of clinics in the community.
i. Engage existing network of partners (first or second round SHIP partners).
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ii. Consider approaching local Health Care Home clinics.
B. Contact clinic staff or clinicians, if possible, to schedule in-person meetings.
C. Review the measures clinics are responsible for reporting related to weight and
tobacco use assessment, counseling, and referral services.
D. Present SHIP materials, clinic tools, and clear vision: “This is what SHIP can offer
you….”
i. Develop a plan/training to educate clinicians and clinic staff about the
Clinical-Community Linkages strategy and objectives.
ii. Include materials/handouts, food and refreshments.
E. Ask clinic staff to identify any clinician “champions” within their clinics or health
care systems.
Potential Milestones
 List of potential partners (clinics) generated
 List of potential clinician champions generated
 Information on clinic measures gathered
 Training planned and scheduled
 Grantee-clinic partner commitment agreement signed, with each party’s role
delineated
Resources
 Sample Recruitment Letters (Appendix E)
 Sample Recruitment Information (Appendix F)
 Clinician Talking Points (MDH will provide these at a later date)
 Clinician Champion presentations
o Dr. Neal Holtan and Sofi Ali’s PowerPoint presentation (Appendix G)
o Dr. Courtney Jordan’s webinar and presentation
 Uniform Data System (UDS) and Healthcare Effectiveness Data and
Information Set (HEDIS) Measures (Appendix H)
2. Establish clinic-specific planning groups
Grantees will facilitate the formation of clinic-specific planning groups which have
been shown to markedly increase the success of implementation and sustainability.
Grantees may also consider using an area advisory committee to provide guidance,
oversight, and coordination of SHIP Clinical-Community Linkages for Prevention
strategy within their region.
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A. Facilitate the formation of clinic-specific planning groups. The purpose of each
planning group is to determine priorities, provide input on the planning and
implementation of the strategy steps, and assist with evaluation activities.
Members may include (but are not limited to) clinician champion, clinic manager,
TA providers, medical assistants, nurses, quality improvement staff, health
educators, nutritionists, community health workers, and other partners.
i. Ask clinic administration to identify and confirm group members.
ii. Schedule meetings, ideally monthly or more often to track progress,
conduct assessment and develop clinic action plan.
iii. Utilize the first or second meeting to provide a general overview of SHIP
and the SHIP Clinical-Community Linkages for Prevention strategy steps,
including a suggested timeline and plan.
3. Collect baseline assessment data from clinic partners
Grantees will conduct baseline assessments of clinic partners to determine:
 Organizational readiness to change
 Quality improvement culture
 Current systems, practices, measures, and documentation related to:
o screening for BMI and tobacco use/exposure
o screening for nutritional and physical activity behaviors (optional for
new grantees or grantees who have not addressed the ClinicalCommunity Linkages for Prevention strategy)
o addressing BMI and tobacco use/exposure
o referring to community resources
A. Select assessment instrument/tool from list below (see Resources).
B. Conduct baseline assessment with each clinic partner to determine current
systems, practices, and measures (if any) related to the Clinical-Community
Linkages for Prevention strategy.
C. Collect and manage data.
Potential Milestones
 Baseline assessment conducted
4. Analyze baseline assessment data
Grantees will work with participating clinics to interpret baseline assessment data
and determine priorities/focus areas as well as technical assistance needs.
A. Analyze data.
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B. Organize findings in a useable format.
i.
Create presentation of clinic assessment, patient and provider survey
results (to be presented at collaborative or meeting with clinic to
determine protocols/process for referrals at that clinic).
C. Share findings with clinic planning group.
i.
Conduct Staff/Provider Focus Groups to get more clarity on
clinic/provider survey results and ascertain further feedback from
providers on current referral processes and needs.
D. Based on findings, determine priorities. Incorporate findings into action plan or
work plan.
Potential Milestones
 Baseline data generated and analyzed
 Process flow chart of current clinic practices developed
 Staff/Provider focus groups conducted
 Findings shared with planning group
 Priorities/focus areas determined
Resources
 Health Care Provider/Staff Focus Groups: Informed Consent and Questions
(Appendix J). Get feedback from providers on current referral process and
needs to 1) identify opportunities for process improvement within the clinics;
and 2) to inform the development of a broad-based referral directory.
Discuss when to implement a quality improvement cycle for adapting clinic
processes i.e. before or after formal referral system is developed. To be
conducted after the initial Clinic, Provider, and Patient Surveys are complete
and before intervention implementation.
 Americans in Motion–Healthy Interventions (AIM-HI). Offers resources for
family physician practice staff to serve as role models for patients. See page
7, step 3 of the AIM-HI Practice Manual for information on adjusting office
processes and procedures.
http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/pub
_health/aim/practicemanual.Par.0001.File.dat/AIMPracticeManual.pdf
 SHIP Clinic Assessment Summary Form (Appendix K)
 SHIP Health Care Tracking Worksheets (Appendix L)
5. Develop clinic-specific action plans
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Using results from baseline assessment, grantees will work with clinic partners to
develop clinic-specific action plans, including mapping current and proposed clinic
flow process. Details included in the plan include what it will take to get to the
proposed clinic flow process.
A. Outline priorities and focus areas with planning group.
B. Consider worksite wellness.
Americans in Motion–Healthy Interventions (AIM-HI) is an American Academy of
Family Physicians initiative that encourages family physicians to be fitness role
models for staff and their patients by offering information and resources to
create a fitness focus in their office environment (see Resources below).
C. Create overall action plan for addressing priorities, including timelines.
D. Develop clinic-specific action plans.
i.
ii.
iii.
Map out readiness to change and ensure the plans are based on
addressing the clinic partner’s needs.
Map out the clinic patient flow goal and ensure plans are largely based on
how to get to that revised clinic flow.
Include a budget (for purchase of new items such as BMI posters).
E. Indicate technical assistance needs.
F. Pilot plans and revise accordingly using PDSA tool (see Resources below).
Potential Milestones
 Organization has a culture that is ready to change.
 Action plan has been developed and vetted through clinic.
Resources
 MDH Quality Improvement tool: Plan Do Study Act (PDSA)
http://www.institute.nhs.uk/quality_and_service_improvement_tools/qualit
y_and_service_improvement_tools/plan_do_study_act.html
 Action Plan templates
o Minneapolis SHIP Resource and Referral Network Clinic Action Plan
template (Appendix M)
o Clinic Action Plan Tracking Tool (Appendix N)
o Carver-Scott Health Care Action Plan template (Appendix O)
 AIM-HI Resources:
http://www.aafp.org/online/en/home/clinical/publichealth/aim/about.html
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Continuous Quality Improvement for Prevention
After completing or updating the planning and assessment phase, grantees will continue
to work with the community to build infrastructure where needed and support their
clinic partners by:
1. Based on gaps identified in the environmental scan of evidence-based lifestyle
change programs such as the Diabetes Prevention Program (DPP), Chronic
Disease Self-Management Programs (CDSMP), pediatric weight management
programs and tobacco cessation programs, support infrastructure development
to increase access to evidence-based programs in the community.
2. Support the implementation of evidence-based clinical guidelines by health care
providers for adults and children where applicable; ICSI Guidelines: Healthy
Lifestyles, Preventive Services for Adults (Hypertension, lipid, tobacco use
screening and brief intervention), Preventive Services for Children and
Adolescents, Prevention and Management of Obesity (Adults). Other Guidelines
may include but are not limited to: American Academy of Pediatrics’ Bright
Futures, Academy of Breastfeeding Medicine.
3. Support the SHIP clinical system process of “Screen, Counsel, Refer and Followup,” by providing direct technical assistance or by offering trainings such as
motivational interviewing, health coaching, tobacco cessation specialist
certification or other types of training.
The grantees will be required to complete the baseline data collection survey for each of
the clinic partners. MDH will provide an electronic link to access the survey. To review
the SHIP 2.0 baseline data collection survey, check the Health Care section from the
following link http://www.health.state.mn.us/healthreform/ship/evaluation2.html.
Step 1: Screen
Primary Aim
Clinicians will screen all patients (adults and children) at preventive and chronic disease
visits (or a minimum of annually) for BMI and use/exposure of tobacco. Clinicians will
document results in the medical record.
Secondary Aim
Clinicians will screen all patients (adults and children) at preventive and chronic disease
visits (or a minimum of annually) for physical activity patterns and nutrition habits.
Clinicians will document information in the medical record. Grantees working with
clinics that are further along in this work should consider working on the secondary aim.
Description
Screening patients to measure their lifestyle risks is the first step in a clinical
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intervention to address lifestyle risk factors. Gathering patient BMI requires measuring
patient weight and height and using these to calculate BMI, and screening patients for
tobacco use/exposure requires questioning patients about their tobacco
behaviors/exposures. Measuring height and weight, calculating BMI, and asking patients
about their tobacco use/exposure must be developed as a consistent process within
every preventive and chronic disease management visit so that they are collected at all
non-acute visits, and at least annually for all patients.
Screening patients and documenting physical activity patterns and nutrition habits will
provide additional helpful information to clinicians as they discuss goals and plans to
improve the patient’s health (Step 2).
Results of patient BMI calculations, and answers to questions regarding patient tobacco
use/exposure, physical activity patterns and nutrition habits must be documented in the
patient chart before the clinician sees the patient that day so that the clinician has the
information available for discussion at that appointment. An Electronic Health Record
may automatically calculate BMI, but this alone does not guarantee that the information
is readily available to the provider seeing the patient that day. Process steps need to be
built to ensure clinicians consistently have the information available to them as they
meet with patients. This often includes visual reminders such as chart alerts, notes, BMI
posters by the scales and in exam rooms and/or electronic chart flagging to bring the
clinicians’ attention to the patients’ BMI and lifestyle risk results. Clinics vary in their
reminder/flagging systems, and utilizing methods that clinicians are already accustomed
to at each clinic is often effective.
Outcome
BMI and tobacco use/exposure are screened and documented.
Implementing Step 1: Screen
#1:
Develop
New
Process
#2:
Pilot New
Process
#3:
Train Staff
on New
Process
#4:
Implement
New Process
#5:
Evaluate
Implementation
1. Develop new screening process (measurement, documentation and clinic flow)
A. Determine if clinic needs additional lifestyle risk measurement tools and/or
questions to add to their current intake forms.
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B. Consider needs of Step 2 (address risks) and Step 3 (refer to resources) when
developing documentation—insure documentation is used as a flag/trigger for
addressing risks and referring to resources.
C. Develop new forms (paper and/or electronic) to gather the required information.
D. Diagram the revised clinic process flow including:
i.
ii.
Which staff accomplish each part of the process
Existing or new tools (forms, reminders, etc.) used throughout process
Potential Milestones
 Clinic has decided what lifestyle risk information they want gathered
 Clinic has developed forms that gather lifestyle risk information
 Revised clinic flow process has been developed that insures gathering and
documentation of all information, including who will accomplish each part in
the process
Tools
 SHIP Lifestyle Risk Tool (Appendix P)
 Health Behavior Assessment (Appendix Q)
 5-2-1-0 Healthy Habits Survey (recommend for pediatric population;
Appendix R)
Resources
 Your BMI Handout (Appendix S)
 AIM-HI Fitness Inventory (includes a total of 19 questions covering activity,
healthy eating and emotional well-being):
http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/pub
_health/aim/fitnessinventory.Par.0001.File.dat/FitnessInventory.pdf
2. Pilot new process
A. Conduct a pilot to test the new process (for example, one or two clinicians for a
day or two) using a Plan, Do, Study, Act model for quality improvement.
B. Review pilot results and change process based on what you’ve learned.
C. Re-pilot and re-evaluate the process until it works smoothly.
Potential Milestones
 Pilot is conducted
 Process is finalized
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Resources
 MDH PDSA Storyboard Template (Appendix T)
 MDH PDSA Worksheet (Appendix U)
 RWJF Pre Practice Assessment Instrument:
http://www.prescriptionforhealth.org/results/NCObservationInstrument.doc
 RWJF Post Practice Assessment Instrument:
http://www.prescriptionforhealth.org/results/NCObservationInstrumentFU.d
oc
3. Train staff on new process
A. Schedule a time when all relevant staff can be trained on the new process.
B. Provide training to staff on new process, including new expectations for their
roles and how process improvement will be evaluated.
Potential Milestones
 Training completed
4. Implement new process
A. Pick a start day for the new process to be universally implemented on the entire
target population.
B. Implement new process.
Potential Milestones
 New process implemented for entire target clinic population
5. Evaluate implementation
A. Use chart audits or other quality improvement measurement tools monthly.
B. Share progress with clinicians.
C. Gather feedback; determine and address needs for full implementation of the
process.
Potential Milestones
 Chart audit conducted monthly
 Chart audit shows consistent implementation of the process
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Step 2: Counsel
Primary Aim
Clinicians will counsel regarding BMI and tobacco use/exposure with every patient at
every visit; counseling and patient response will be documented in medical record.
Secondary Aim
Clinicians will counsel regarding nutrition habits, including pregnant women for herself
and baby, and physical activity patterns with every patient at every visit; counseling and
patient response will be documented in medical record.
Description
After the clinician/staff or clinical team screened and documented BMI and tobacco
use/exposure (and nutrition and physical activity, if desired), the next step is to counsel
each patient.
The task for each grantee in Step #2 – Counsel is similar to that of Step #1 - Screen in
that the grantee must support and assist each health care partner as they systematically
incorporate patient counseling (as with screening) into a new or revised clinic system
while enhancing clinician/staff work flow. This truly requires systems redesign and
fostering a culture of change through the entire process. Counseling refers to clinicians
advising patients of risks of current BMI or tobacco use/exposure status and the
benefits of change, assessing patients’ readiness to change, and assisting with care plan
creation for one to two patient-identified health goals. Grantees working with clinics
that are further along in this work should consider working on the secondary aim as
well.
Outcome
Results of BMI status and tobacco use/exposure (and healthy eating and physical
activity if these behaviors are also being measured) discussion are documented.
Implementing Step 2: Counsel
The following should be implemented following completion of Planning and Assessment
and Step 1: Screen. Additionally, adopting and implementing a Worksite Wellness Policy
(for the clinic staff) is suggested prior to initiation of Step 2: Counsel. Finally, these
activities should be implemented in conjunction with clinic partners.
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1. Develop new counseling process
A. Diagram current process, compare to evidence-based recommendations, and
identify gaps.
B. Develop and diagram revised process that will support counseling, incorporating
feedback from clinic planning group.
C. Identify and obtain resources and tools needed for revised process.
Potential Milestones
 Process outline revised into a swim lane diagram (see Resources below)
based on clinician and staff feedback in order to delineate clinician and staff
roles
Resources
 AIM-HI Practice Manual (page 7, step 3). Adjust Office Processes and
Procedures (evaluate patient flow including patient visit flow chart):
http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/pub
_health/aim/practicemanual.Par.0001.File.tmp/AIMPracticeManual.pdf
 Act and Ask Practice Manual (pp. 4-5 and 18-19):
http://www.msafp.org/upload/file497_AAFPPracticeManual.pdf
 Flow Chart and Swim Lane Templates:
http://office.microsoft.com/en-us/visio-help/create-a-cross-functionalflowchart-HP010357078.aspx
 MDH SHIP QI Collaborative Monthly Report Forms and Storyboard Template.
o MN Public Health Collaborative for Quality Improvement Obesity
and Tobacco Use (SHIP) Monthly Report Form (Appendix V)
o MDH PDSA Storyboard Template (Appendix T)
o MDH PDSA Worksheet (Appendix U)
 Institute for Clinical Systems Improvement Prevention and Management of
Obesity Guideline (May 2013):
https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catal
og_guidelines/catalog_endocrine_guidelines/obesity__adults/
2. Train staff on new counseling process
A. Identify training needs, which may include the following:
o Motivational Interviewing Techniques
o Documentation training
o Role Training and Talk-back Session
B. Arrange sessions to cover all clinic team members.
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C. Complete sessions and administer post-test to evaluate learning.
Potential Milestones
 Training completed
Resources
 Motivational Interviewing in Health Care: Helping Patients Change Behavior
by Stephen P. Rollnick, William R. Miller, & Christopher C. Butler:
http://www.amazon.com/Motivational-Interviewing-Health-CareApplications/dp/1593856121
 Sue Eckmaahs, Motivational Interviewing Trainer:
http://www.eckmaahs.com/home
 Collaborative Decision-Making and Brief Interventions (Appendix W)
3. Implement new counseling process
A. Create action plan to implement new process.
B. Create, run, and evaluate new process using pilot test and/or Rapid Cycle PDSAs.
C. Develop prompts for staff and clinicians and provide incentives for
clinicians/staff who implement new process correctly and consistently.
D. Embed new process in paper chart or EMR.
Potential Milestones
 Action plan implemented and rapid cycle PDSAs completed
 Prompts implemented and paper chart or EMR adapted to incorporate new
process
Resources
 MDH QI Collaborative PDSA Tools:
Obesity and Tobacco Use Monthly Report Form
http://www.minneapolismn.gov/www/groups/public/@health/documents/
webcontent/convert_270986.pdf
PDSA Worksheet
http://www.minneapolismn.gov/www/groups/public/@health/documents/
webcontent/convert_269959.pdf
 AIM-HI Practice Manual:
http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/pub
_health/aim/practicemanual.Par.0001.File.tmp/AIMPracticeManual.pdf
 Act and Ask Practice Manual:
http://www.msafp.org/upload/file497_AAFPPracticeManual.pdf
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4. Evaluate implementation of new process
A. Contact health care partner at least monthly to review progress.
i.
ii.
iii.
iv.
v.
Discuss successes and barriers; assist to overcome barriers.
Discuss next steps and plans for sustainability.
Offer resources, tools and support as needed.
Schedule quarterly on-site visit.
Provide health care partner with feedback, encouragement and
motivation to continue the process.
B. Use chart audits or other quality improvement measurement tools monthly.
C. Share progress with clinicians.
D. Gather feedback and determine and address any needs for full implementation
of the process.
Potential Milestones
 Progress call conducted monthly
 On-site visit completed
 Chart audit shows consistent implementation of the process
Resources
 Glasgow et al., D.C. (2006). Assessing delivery of the five ‘As’ for patientcentered counseling.
Step 3: Refer
Primary Aim
Clinicians will refer patients who are overweight or obese and/or who use tobacco to
local resources that increase access to high quality nutritious foods, opportunities for
physical activity, and tobacco use cessation education and support, ultimately leading to
behavior change. Clinicians will document referrals in the medical record.
Secondary Aim
Clinicians and clinic staff will develop relationships with community organizations and
leaders that build partnerships to facilitate referral of patients to local resources that
increase access to high quality nutritious foods, opportunities for physical activity, and
tobacco use cessation for education and support, ultimately leading to behavior change.
Description
Beyond their traditional role of informing patients of their health status and giving
general directives to improve that status, clinicians should be aware of and recommend
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programs, services, and activities (from here on referred to as “resources”) that can help
patients work to achieve those general directives. These resources can be clinic-based
services and programs (in-house or referred out); programs, places or activities in the
community; and/or self-management activities conducted by the patient in their home
or daily life. Initially, clinicians and clinic staff must be aware of local resources, including
their focus, schedules, and target population as well as the clinic’s patient population
needs and preferences for resources (e.g. location, cost, language, etc.). Clinicians and
clinic staff will also need access to an updated list or database of information on
available local resources, such as www.MNHelp.Info, and a process to use it within the
clinic.
Clinicians must use their roles as clinicians, community leaders and health advocates to
convey a clear, strong, personal message about the advisability and benefits of health
behavior change (complimenting Step 2). In addition, they must provide a referral to
community-level resources appropriate to their patients’ health conditions, current
health status, and degree of motivation and document it in the medical record. An
effective system of referral of patients to resources focused on nutrition, physical
activity and tobacco cessation will require a high level of communication and
coordination. A system must be in place at the clinic to document the referral in the
medical record and if necessary, involve the health care team to carry out different
components of the referral process (e.g. locating and selecting a resource, tracking
referrals, arranging transportation, etc.). Clinics should be able to provide patients with
handouts, links, or contact information to resources before they leave the clinic, to
increase the likelihood that patients will follow-through. Additionally, scheduling
referral appointments, utilizing referral forms or electronic referrals, and developing
relationships with resource agencies for a warm hand-off will help facilitate followthrough by the patient.
Outcome
Referral to resource is documented.
Implementing Step 3: Refer
#1: Engage
Community
Stakeholders
#2: Inventory
Existing
Referral
Resources
#5: Train
Clinicians and
Clinic Staff on
New Process
for Referrals
#3: Establish
Clinic-Specific
Referral
Resources and
Partnerships
#6: Implement
Referral
Process and
Resource
Database
#4: Develop
New Process
for Referrals
#7: Evaluate
Implementation
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1-3.
Identify resource gaps and develop referral partnerships
A. Work with partner clinics to identify current clinic specific referral resources
through assessment (general clinic assessment, provider survey and focus group,
patient survey).
B. Work with partner clinics to establish clinic-specific referral resources as
described in the table below:
Risk Factor
Tobacco
Physical
Activity
Clinic-based
Train clinicians to
offer on-site
tobacco cessation
classes such as
Freedom From
Smoking; offer
clinician or
pharmacist
cessation
counseling; other
clinic-based
tobacco cessation
counseling off-site
Internal or external
clinicians such as a
health coach or
physical therapy;
conduct on-site
group exercise
classes utilizing
Kinesiology Interns
from your local
University
Nutrition
Weight and Chronic Disease
Management
Type of Referral Resource
Community
Self-Management
Enroll in or improve
Online tobacco cessation tools through
referral processes
QuitPlan, their health insurer, etc.
for MN Clinic Fax
Referral Program;
MN QuitPlan
services
Public or private
health clubs (YMCA,
YWCA), Community
Education and Parks
and Recreation
exercise classes,
local parks and
trails, sports
leagues, etc.
Exercise videos, exercise tutorial hand-outs,
hand-outs on how to get small bouts of
exercise, or home exercise equipment (hand
weights, exercise ball, etc.)
Internal or external
clinicians such as RD
or health coach;
provide nutrition
classes on-site
utilizing RD, UMN
Extension, or RD
interns from your
local University,
lactation counselor
Internal or external
clinicians such as RD
or clinical weight
management, offer
prediabetes (I Can or
YDPP) or chronic
Nutrition classes
through Community
Education, Parks and
Recreation
programming and
UMN Extension;
farmer’s markets,
Fare for All and
other places to
access healthy foods
Public or private
weight management
classes such as
Weight Watchers,
prediabetes classes
(I Can or YDPP),
Informational
handouts on eating
well, recipes, food
logs, etc.
Educational
information and tips
on losing weight
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disease prevention
classes (CDSMP) onsite
chronic disease
prevention classes
(CDSMP), and other
evidence-based
classes
C. Develop clinic specific list of selected resources and informational hand-outs.
D. Create partnerships/relationships with the most relevant and important
community resource agencies and create a warm hand-off process with a
referral form.
i.
ii.
Conduct community agency assessment (see Evaluation Tools).
Facilitate partnership meetings, presentations, or conversations between
providers and community agencies.
B. Identify gaps in community and clinic based programs at individual clinics
through assessment.
C. Develop new resources to address gaps at individual clinics via additional clinical,
community and self-management resources.
i.
ii.
Identify clinics and agencies that are best-suited to offer programs on-site
and facilitate implementation (e.g. I Can Prevent Diabetes and CDSMP).
Facilitate partnerships or conversations between clinic and community
agencies to offer new or additional programming in the community for
referral.
D. Work with clinic to develop a plan for sustaining partnerships and making
updates/changes to referral resource system.
Potential Milestones
 Clinic-specific resources identified and list developed
 At least one new partnership with a community organization has been
developed and a clinic referral process to the resource developed
Resources
 Resource List Examples (Appendix II)
 Warm Hand-off Process Map (Appendix JJ)
 Referral Form Examples
o Healthy Living, Minneapolis (Appendix KK)
o Lifestyle Action Plan, Hennepin County (Appendix LL)
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4. Develop new process for referrals to clinical, community and self-management
resources
A. Familiarize yourself with existing clinic referral systems and coordination models
(CHW, EMR, warm hand-off, etc.) and assess feasibility for use with partner
clinics based on clinic assessments.
B. Determine current referral process at the clinic and address barriers.
i.
ii.
Use clinic assessment and staff/provider surveys and focus groups to
determine current process for referrals, e.g. where resources are and
what processes are required. For example, if your organization refers
patients to an outside source, what are the criteria for referral?
Ascertain data specific to registration in the Call It Quits Fax Referral
System and the number of providers that actively refer patients.
C. Determine how to integrate resources into clinic process (how to link patients
with these resources).
i.
ii.
iii.
iv.
v.
vi.
Map out current clinic processes for referral (PA, tobacco, HE).
Make changes to map ideal process and tools necessary (provider
conversation, responsible referral person, assessment tools, readiness
tools, clinic decision support/EMR integration).
Create a warm hand-off process and referral forms (see Additional
Resources under step 5 for examples).
Conduct clinic process changes for referrals (PDSA, lean management,
etc.).
Conduct Plan-Do-Study-Act cycles (PDSAs) to make desired changes.
Finalize ideal process for referrals in clinic.
Potential Milestones
 Clinics have developed new process for referral of at-risk patients
Resources
 Referral Model Grid, Minneapolis (Appendix MM)
 Health Care Referral and Follow-Up Model Map, Minneapolis (Appendix NN)
 MDH QI Collaborative PDSA Tools (Appendices T, U, V)
 MN Tobacco Fax Referral Process (Appendix OO)
5. Train staff on new referral process
A. Present new process to clinic staff and get input.
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B. Conduct provider/staff training on clinic referral process/protocols, available
resources and how to use the “Power User” features of MNHelp.Info to access
saved favorites list (Saved Plans), conduct keyword searches and create printable
directories (Saved Directories).
C. Work with individual partner clinics on saving favorite resources, integrating into
referral processes, and provide staff/provider training.
Potential Milestones
 Clinic staff have been trained on resource database
 Clinicians and clinic staff have been trained on new process for referral of atrisk patients
6. Implement new referral process and resource database
A. Partner clinics implement use of referral process and resource database using
clinic action plan.
Potential Milestones
 Clinic specific process for referrals to resources has been developed
 Clinic specific process for referrals to resources has been implemented
Resources
 SHIP Health Care Provider Toolkit for Obesity and Chronic Disease
Prevention. Initial toolkit to contain brief (1-2 pages) information on referral
resources to include: 1) Evidence based community interventions
(reimbursement), 2) list of current referral databases/directories, and 3)
select other resources from ICSI guidelines or otherwise. To access this
toolkit, please contact SHIP Health Care Strategy Coordinator Cherylee
Sherry, MPH, CHES at Cherylee.Sherry@state.mn.us
 Supporting Breastfeeding and Lactation and Get Reimbursed
https://www2.aap.org/breastfeeding/files/pdf/coding.pdf
 Referral and Prescription Forms:
o Let’s Move (Appendix PP)
o AIM-HI Prescription (Appendix QQ)
o Parks Prescriptions:
http://www.parksconservancy.org/assets/conservation/environment
al-sustainability/pdfs/park-prescriptions-2010.pdf
Prescribing Public Lands for Health
http://www.youtube.com/watch?v=ZfIT7kH_KQY
o Exercise is Medicine:
http://www.exerciseismedicine.org/documents/B_ExPrescripReferral.
pdf
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o Blend:
http://www2.aap.org/obesity/whitehouse/Rx%20COLOR%201%20up
%20v2.pdf
7. Evaluate implementation of new referral process and resource database
A. Conduct baseline assessment of number of referrals and track increase
(including the Call It Quits Fax Referral program).
B. Collect outcome and process measures and report progress towards goal and
aims.
C. Review ongoing clinic progress and provide updates to clinic staff and providers
at meetings.
D. Assist clinic to conduct continuous quality improvement to increase referrals to
resources.
Potential Milestones
 Assessment tools completed
 Survey/ focus group of clinic staff completed
Step 4: Follow-Up
Primary Aim
Clinics will follow-up with at-risk patients to provide support and encouragement,
ensure accountability, and evaluate patient’s progress towards achieving a healthier
lifestyle.
Description
As follow-up is integrated into the fabric of the medical encounter, this further
coordination can increase patient outcomes. A follow-up visit can be arranged for
separate visits or during the next routine medical visit. During these visits, patients’
participation in referral resources should be assessed.
As relationships and communication between clinicians, in-house and community
resources, and patients grow, clinics should implement systems that ensure consistent
follow-up between medical visits to assess participation in programs to which patients
were referred. This allows the clinician to assess progress, learn about and resolve
barriers, and suggest additional or different activities. Community organizations should
be encouraged to play a role in following-up with patients by communicating outcomes
with clinics. Clinics can arrange partnerships with agencies to take on the responsibility
of the referral by reporting back to the clinic via a referral form.
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Outcome
Clinics/community organizations track patient access and utilization of referral
resources. Patient follow-up is completed with evidence documented of patient
utilization of referral and/or behavior change.
 Definition of Policy for Follow-Up: Relationship between clinics and referral
entities grows; communication infrastructure is established and allows feedback
on referrals to flow between clinicians and clinical, community and selfmanagement resources.
Requirements
 Process for securing patient data or de-identifying patient information if
necessary
 Providing classification of referral type used: e.g., in-clinic, out-clinic, community
non-profit, community private partner, etc.
 Classification of referral follow-up used: e.g., follow-up call, follow-up email,
clinic or referral agency raw numbers, flag/documentation in patient chart at
next visit (within 6-12 months)
Implementing Step 4: Follow-Up
#1: Assist
Clinics in
Developing a
Process for
Tracking
Referral
Utilization
and Behavior
#2: Create
Necessary
Forms to
Support
Referral
Follow-Up
Tracking
Process
#3:
Implement
and Evaluate
Referral
Follow-Up
Process
#4: Write
Policy to
Sustain
Change
1. Develop new process for tracking referral utilization and behavior change (for each
type of referral utilized for the clinic)
A. Review survey feedback on clinic referral process completed in step 3.
B. Incorporate clinic needs assessment and build on existing referral work plan.
Types of referrals may include:
i.
ii.
iii.
iv.
v.
Clinical referrals (e.g., case manager, dietitian, health coach, physical
therapy)
Community referrals
Non-profit organization referrals (e.g., YMCA, health plan)
Private organization referrals (e.g., Weight Watchers)
Self-management resources or programs (e.g., home-based exercise
handouts, personal diet or exercise regimen)
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Potential Milestones
 Clinics have incorporated activities into their action plans for increasing
follow-up on referrals for at-risk patients
 Follow-up process training complete for clinic staff and use integrated into
practice within 6-12 months
Additional Resource
 See Step 3 Referral Resource Lists
2. Create necessary forms to support referral follow-up tracking process (or electronic
eLinks system can be used for electronic referral from EMR or MNHelp.Info)
A. Assist with chart flag/ pop-up and or clinician note template for referral followup creation.
B. Conduct a trial or pilot follow-up call/discussion interview model.
C. Conduct follow-up process PDSA review and make necessary changes.
Potential Milestones
 Template for note complete, model interview script finalized, both in use in
clinic
 Pilot of follow-up process complete.
Resources
 Sample Referral and Prescription Forms (see under Step 3: Referral, 3 and 6)
3. Implement referral follow-up process
A. Partner clinics implement follow-up process according to clinic action plan.
Potential Milestones
 Clinic specific process for referral follow-up has been implemented
4. Evaluate referral follow-up process
A. Collect outcome and process measures and report progress towards goal and
aims.
B. Review ongoing clinic progress and provide updates to clinic staff and providers
at meetings.
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C. Assist clinic to conduct continuous quality improvement on referral and followup process.
D. Build on relationship with referral resource partners established in Step 3 to
relay follow-up data and continue relationship building to enhance referral
utilization.
Potential Milestones
 Evaluation of first 6 months of follow-up process completed
5. Amend existing clinical practice policy to include follow-up component.
Sustaining Long-Term Change
1. Write policy to sustain change
A. Determine if writing a policy will assist in sustaining the revised practice.
B. Write the policy.
C. Share the policy following clinic standards for new policy dissemination.
Potential Milestones
 Policy written
 Policy shared
Resources
 Evidence-Based Practice, Step by Step, American Journal of Nursing:
http://journals.lww.com/ajnonline/pages/collectiondetails.aspx?TopicalColle
ctionId=10
 Sustaining Change: Once Evidence-Based Practices Are Transferred, What
Then? Tazim Virani, Louise Lemieux-Charles, David A. Davis and Whitney
Berta
http://www.longwoods.com/content/20420
 Chapter 7. The Evidence for Evidence-Based Practice Implementation, Marita
G Titler
http://www.ahrq.gov/professionals/cliniciansproviders/resources/nursing/resources/nurseshdbk/TitlerM_EEBPI.pdf
Innovations or Promising Practices
The following are examples of Innovations or Promising Practices for the Clinical
Community Linkage strategy:
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1. Support the use of health care extenders (i.e. health educators, community
paramedics, nutritionists, etc.) and education/navigation extenders (i.e.
community health workers, community health representatives, patient
navigators, etc.) to improve engagement of disparate populations in evidencebased lifestyle change programs.
2. Collaborate with behavioral health clinic staff to address tobacco cessation in
adults with mental illness.
3. Support the use of Screening, Brief Intervention, Referral to Treatment (SBIRT)
model in clinical settings for specific populations, e.g. adults over 60yrs.
Advancing Public Health, Health Care and Community
Linkages with State and Federal Health Reform Initiatives
Strategy
As MDH considered revisions to the SHIP 3.0 menu of health care strategies, staff took
into consideration how the health care scene has changed since the inception of SHIP
when the original health care strategies were developed. These changes include:





Development of health care homes within primary care clinics. They are
intended to incorporate clinical preventive services for persons with chronic and
complex conditions;
Maturing of Minnesota’s health reform strategies that are having an impact on
changing clinical practices to achieve improved health outcomes (e.g. public
reporting; transition from volume-based reimbursement to reimbursement for
outcomes; etc.);
Increased awareness of evidence-based chronic disease self-management
programs, although not always accessible in some communities;
Enactment of federal health reform, which has included a focus on prevention as
well as the emphasis on clinical and community linkages;
Recent CMS award of the 3-year State Innovations Model (SIM) grant to
Minnesota, which among other actions, intends to support the building of
Accountable Communities for Health in 15 communities. This represents an
opportunity for LPH to serve as a catalyst in bringing together citizens to shape
the future system of care in their communities.
Scope of Component
To purposefully insert the expertise of LPH into the health reform discussions at the
community level in order to bring added value to the overall goals of improved
population health.
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Phase 1: Planning and Assessment
 Partner with local hospital(s) in conducting their community needs assessments
Resource
Association for Community Health Improvement (ACHI) http://www.assesstoolkit.org/
Models of Community Engagement
http://www.health.state.mn.us/communityeng/intro/models.html
Phase 2: Growth
 Reach out to local certified health care home clinics or clinics working to obtain
health care home certification to participate on clinic’s community health team
Resources
MDH Health Care Homes http://www.health.state.mn.us/healthreform/homes/
MN Community Health Worker Project
http://www.health.state.mn.us/ommh/projects/chw.html
MN Community Health Worker Alliance http://mnchwalliance.org/
Hennepin Tech Community Paramedic Program
http://www.hennepintech.edu/customizedtraining/cts/44#&panel1-1
Phase 3: Innovation and Promising Practices
 Act as a catalyst in bringing together citizens and organizations to shape the
future system of health care in the community.
 Grantees will create an action plan for the activity (s) they intend to address.
Resources
Minnesota Area Health Education Centers
http://www.mnahec.umn.edu/regions/home.html
Accountable Communities for Health – To be selected in 2014
http://www.health.state.mn.us/healthreform/sim/minnesotaaccountablehealthmodels
ummary.pdf
Requirements
The grantees will be required to:


Work on both strategy components
Complete the baseline data collection survey with each of the clinic partners.
MDH will provide an electronic link to access the survey. To review the SHIP 2.0
baseline data collection survey, check the Health Care section from the
following link
http://www.health.state.mn.us/healthreform/ship/evaluation2.html.
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
Use evidence-based programs when assisting to build infrastructure for
referrals. The following evidence-based community interventions have been
proven effective in promoting the skills needed to build self-efficacy in selfmanagement of health behaviors. These programs include:
o Lifestyle Balance programs (i.e., Diabetes Prevention Program or I CAN
Prevent Diabetes) – modest 5-10 percent weight loss by increased
physical fitness, improved diet, increased self-monitoring and self-care
o Chronic Disease Self-Management Program – demonstrated increase in
physical activity and healthy eating
o Arthritis Self-Management Program – demonstrated increase in physical
activity and healthy eating
o Matter of Balance – demonstrated increase in physical activity
o Arthritis Foundation Exercise and Warm Water Exercise programs –
increased physical activity
o Tobacco cessation Quit Lines (i.e. MN Clinic Fax Referral Program)


Participate in regular learning meetings established by MDH. The meetings are
yet to be determined.
Participate in monthly conference calls which will be separated into those new to
health care and those who have been working on health care in SHIP 2.0.
Recommended Partners and Potential Responsibilities
Minnesota Department of Health (MDH)
 Coordinate state policy work to support LPH.
 Provide technical assistance and resources to LPH.
 Convene grantees through connect calls to share tools, knowledge and
experience with strategy implementation.
Local Public Health (LPH) (referred to in this document as “grantees”)
 Recruit health care partners.
 Conduct baseline assessment, analyze results and share findings with planning
groups.
 Develop or identify resources that support strategy implementation including
surveys, clinician materials, EMR measures, sample policies, etc.
 Work with clinic partners to identify or develop in-house, home-based and
community-based referral resources.
 Identify and/or develop referral and follow-up processes.
 Offer technical assistance and on-site training for clinic partners as needed.
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Clinic Partners (For SHIP 3.0 health care partners will be referred to as “clinic partners,”
whether it is technically a clinic or a health care site.)
 Complete assessments.
 Organize a clinic-specific planning group team (preferably including a physician
or director champion).
 Participate in webinars, face-to-face sessions and conference calls to access
technical assistance.
 Develop and implement action plan.
Settings
(Clinics that are bolded reflect those serving high priority populations.)
Clinical-Community Linkage Strategy:
 Clinics serving high volumes of uninsured (or “self-pay”)
 Clinics serving high volumes of Medicare/Medicaid patients
 Clinics serving Minnesota Health Care Program (MHCP) patients
 Outpatient primary care clinics
 Pediatric clinics
 Physical therapy clinics
 University setting clinics (student health services)
 Occupational health clinics
 Dental clinics
 Women’s health/OB-GYN clinics
 Mental health clinics
 Public health clinics (may include school-based clinics if they exist)
 Visiting Nurse Association
 Health care centers/hospitals
Community-Based Partners
 Community programs and resources that can assist patients in reaching their
goals and/or provide social support for lifestyle change. This could include
groups such as YMCA, YWCA, church groups, youth centers, senior centers,
commercials gyms, community education programs, Minnesota Extension
Programs, Area Agencies on Aging, programs designed for individuals with
particular chronic conditions such as I/We CAN Prevent Diabetes Program,
Chronic Disease Self-Management Program (CDSMP), Arthritis Foundation
exercise programs and warm water exercise, extension education efforts,
walking groups, etc.
 Community-based health or social service coalitions such as local breastfeeding
coalitions, ATOD, Obesity Prevention, Tobacco Cessation, others.
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Training and Technical Assistance
See the separate SHIP 3 Guide to Training and Technical Assistance for an overall picture
of training and technical assistance.
Grantees will be required to participate in monthly conference calls which will be
separated into those new to health care and those who have been working on health
care in SHIP 2.0.
MDH will provide technical assistance for the infrastructure development of the
following programs: I Can Prevent Diabetes and the Chronic Disease Self-Management
Program.
Grantees can make requests for training and technical assistance through the TA
request process (see the SHIP 3 Guide to Training and Technical Assistance).
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Appendices
The following appendices can be accessed at:
http://www.health.state.mn.us/healthreform/ship/Implementation.html under “Health
Care Appendices by Topic.”
A:
B:
C:
D:
E:
F:
G:
H:
I:
J:
K:
L:
M:
N:
O:
P:
Q:
R:
S:
T:
U:
V:
W:
X:
Y:
Z:
AA:
BB:
CC:
DD:
EE:
FF:
5A Concepts and SHIP Prevention in Health Care Steps
SHIP Prevention in Health Care References
SHIP Prevention in Health Care Talking Points
SHIP Prevention in Health Care Terminology and Abbreviations
Sample Recruitment Letter
Sample Recruitment Information - Overview of the Strategy
Dr. Neal Holton and Dr. Sofi Ali's PowerPoint Presentation
UDS and HEDIS Measures
Minneapolis MGI Health Care Work Group Model
Health Care Provider/Staff Focus Group – Informed Consent
NACC Mpls-Hennepin Sample Policy
Anoka County Public Health Nursing Breastfeeding Sample Policy
Minneapolis SHIP Resource and Referral Network Clinic Action Plan template
Clinic Action Plan Tracking Tool
Carver-Scott Health Care Action Plan template
SHIP Lifestyle Risk Tool
Health Behavior Assessment
5-2-1-0 Healthy Habits Survey
Your BMI Handout
MDH PDSA Storyboard Template
MDH PDSA Worksheet
MN Public Health Collaborative for Quality Improvement Obesity and
Tobacco Use (SHIP) Monthly Report Form
Collaborative Decision-Making and Brief Interventions
Referral and Resource Key Informant Interview Themes
MNHelp.Info Inclusion Criteria
Resource Database Attributes and Values
MDH SHIP Guide 2008 List of Evidence-Based Resources
MNHelp.Info SHIP Information Sheet
MNHelp.Info Excel spreadsheet template
MNHelp.Info PowerPoints-MHI Power User Version
MNHelp.Info PowerPoints-MHI Provider Portal Instructions
MNHelp.Info Saved Plans Guide
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GG:
HH:
II:
JJ:
KK:
LL:
MM:
NN:
OO:
PP:
QQ:
MNHelp.Info Keyword Search Guide
Resource and Referral Network Aggregate Baseline Assessment Findings
Resource List Examples
Warm Hand-Off Process Map
Referral Form Examples - Health Living Minneapolis
Referral Form Examples - Lifestyle Action Plan (Hennepin County)
Referral Model Grid
Health Care Referral and Follow-Up Model Map
MN Tobacco Fax Referral Process
Referral and Prescription Forms - Let's Move
Referral and Prescription Forms - AIM-HI
References
1
McGlynn, E.A., Asch, S.M., Adams, J., et al. (2003). The quality of health care delivered to adults in the United States. New England
journal of Medicine, 348, 2635-2645.
2
Balasubramanian BA, Cohen DJ, Clark EC, et al. Practice-level approaches for behavioral counseling and patient health behaviors.
Am J Prev Med 2008;35(5S):S407-S413.
3
Etz, R., Cohen, D., Woolf, S., et al. (2008). Bridging primary care practices and communities to promote healthy behaviors.
American Journal of Preventive Medicine, 35(5S), S390-S397.
4
Prevention Institute, How Can We Pay for A Healthy Population? Innovative New Ways to Redirect Funds to Community
Prevention, January 2013
5
Trust for America’s Health, Issue Brief, Incorporate Prevention and Public Health in a Reforming Health Care System; January 2013.
6
US Department of Health and Human Services (2012). Community Benefit Issue Brief. Available at:
http://www.healthcare.gov/prevention/nphpphc/advisorygrp/gw-community-benefit-issue-brief.pdf
7
Barr VJ, et al. The Expanded Chronic Care Model: An Integration of Concepts and Strategies from Population Health Promotion and
the Chronic Care Model. Hospital Quarterly. 2003. Vol 7(1); 73-82.
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